My next door neighbor is paralyzed from the hips down thanks to Ascension/St Thomas

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The 80-page investigative report released by the Tennessee Health Facilities Commission reveals that the tragedy was caused by multiple systemic and consecutive process failures.

Rather than a single isolated mistake, the investigation detailed a "chain of mistakes" where one safety check after another completely broke down before, during, and even after the incident. The state cited the hospital with three separate instances of "Immediate Jeopardy"—meaning conditions that put patients' lives in immediate danger—across three distinct operational branches: Pharmacy Services, Surgical Services, and the Hospital Governing Body (Management).The specific process failures that occurred at every phase of the care cycle include:

1. The Inventory & Pulling Failure

A pharmacy technician physically pulled the wrong drug—vials of highly dangerous potassium phosphate instead of the requested local anesthetic, mepivacaine.

2. The Tech-Barcoding Failure

When the technician attempted to scan the medication at the workstation, the barcode scanner failed to verify it. Rather than stopping to investigate why the system rejected the drug, the technician overrode or bypassed the warning and proceeded with the preparation anyway.

3. The Compounding & Labeling Failure

The technician prepared five syringes using the incorrect potassium compound but proceeded to slap printed labels on them that falsely identified the medication as mepivacaine.

4. The Pharmacist Verification Failure

The hospital’s internal checks required rigorous oversight. However, the incorrect syringes managed to pass through three pharmacy technicians and one final verifying pharmacist without anyone noticing that the base compound inside the syringes was wrong.

5. The Surgical Administration Failure

Because the syringes were mislabeled by the pharmacy, surgical staff in the operating room failed to catch the error. The "rights of medication administration" (checking the right drug against the right order) failed because the label on the syringe matched the doctor's order, masking the toxic substance inside.

6. Post-Incident Response & Care Failures

The report also cited severe procedural failures regarding how the hospital handled the aftermath:

Delayed Response: There were critical procedural gaps in managing the patients once they began exhibiting severe, deteriorating neurological symptoms, cardiac stress, and respiratory distress.

No Immediate Suspension: The hospital failed to immediately place the involved anesthesiologist on administrative leave pending the investigation.

Lack of Immediate Retraining: Pharmacy workers were not immediately re-trained or systematically pulled from production following the catastrophe.

An outside medical expert brought in by state investigators summarized the disaster plainly: it was a catastrophic environment where "one failure after another by pharmacy employees" was permitted by broader systemic neglect from management.

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What Happened: During routine orthopedic joint replacement surgeries, a pharmacy error led to mislabeled syringes. Instead of receiving the intended spinal local anesthetic (mepivacaine or bupivacaine), at least four patients were injected intrathecally (directly into their spinal fluid) with potassium phosphate

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What context of Ascension are you making reference to?

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My next door neighbor is paralyzed from the hips down thanks to Ascension

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What context of Ascension are you making reference to?

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Ascension Saint Thomas Hospital in Nashville

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This once respected Nashville hospital is now run by jeets. This was completely predictable.

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5. The Surgical Administration Failure

Because the syringes were mislabeled by the pharmacy, surgical staff in the operating room failed to catch the error. The "rights of medication administration" (checking the right drug against the right order) failed because the label on the syringe matched the doctor's order, masking the toxic substance inside.

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